Provider Demographics
NPI:1669973970
Name:FORTSON DENTISTRY LATHRUP NORTH
Entity type:Organization
Organization Name:FORTSON DENTISTRY LATHRUP NORTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:
Authorized Official - Last Name:SOLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-398-5400
Mailing Address - Street 1:27445 SOUTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LATHRUP VILLAGE
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3411
Mailing Address - Country:US
Mailing Address - Phone:248-423-9000
Mailing Address - Fax:
Practice Address - Street 1:27445 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LATHRUP VILLAGE
Practice Address - State:MI
Practice Address - Zip Code:48076-3411
Practice Address - Country:US
Practice Address - Phone:248-423-9000
Practice Address - Fax:248-569-7409
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental